What are common ICU (Intensive Care Unit) protocols?

Common ICU Protocols

Implement an integrated Pain-Agitation-Delirium (PAD) protocol that prioritizes analgesia-first sedation, targets light sedation levels, avoids benzodiazepines, and includes daily sedation interruption or light sedation targets for all mechanically ventilated adult ICU patients. 1

Core Protocol Components

Pain Assessment and Management

• Perform routine pain assessment in all ICU patients using validated tools such as the Behavioral Pain Scale (BPS) or Critical-Care Pain Observation Tool (CPOT) for patients unable to self-report 1, 2
• Administer IV opioids (fentanyl, morphine, or sufentanil) as first-line therapy for non-neuropathic pain, using scheduled continuous dosing rather than as-needed administration 1, 2
• Use non-opioid analgesics (acetaminophen, NSAIDs) as adjuncts to reduce opioid requirements and side effects 1, 2
• Provide preemptive analgesia before painful procedures (only done 20% of the time currently, despite evidence supporting it) 1

Sedation Strategy

• Target light sedation levels where patients can respond to commands (open eyes, maintain eye contact, squeeze hand, stick out tongue, wiggle toes) 1
• Use the Richmond Agitation-Sedation Scale (RASS) or Sedation-Agitation Scale (SAS) to assess sedation depth 1
• Implement either daily sedation interruption OR continuous light sedation targeting (both strategies reduce deep sedation risks) 1
• Avoid benzodiazepines as they increase delirium risk by ~20% and prolong mechanical ventilation 1

Sedative Agent Selection

• Prefer dexmedetomidine over benzodiazepines for mechanically ventilated patients, as it reduces delirium duration and prevalence 1
• Propofol is acceptable for sedation, with maintenance rates of 5-50 mcg/kg/min (0.3-3 mg/kg/h), not exceeding 4 mg/kg/hour 3
• For ICU sedation, initiate propofol slowly at 5 mcg/kg/min and increase by 5-10 mcg/kg/min increments every 5 minutes to minimize hypotension 3
• Avoid abrupt discontinuation of sedatives; taper gradually to prevent anxiety, agitation, and ventilator dyssynchrony 3

Analgesia-First Sedation Approach

• Treat pain before administering sedatives (analgosedation protocol) 1, 2
• This approach reduces continuous sedative infusion use by 54% and decreases ventilator duration by approximately 27 hours 4
• Optimize opioid dosing first, then add minimal sedatives only if agitation persists despite adequate analgesia 1

Delirium Management

Monitoring

• Screen all ICU patients daily for delirium using the Confusion Assessment Method for the ICU (CAM-ICU) or ICU Delirium Screening Checklist (ICDSC) 1
• Recognize that delirium increases mortality, prolongs ICU/hospital length of stay, and causes post-ICU cognitive impairment 1

Prevention

• Implement early mobilization to reduce delirium incidence and duration 1
• Do NOT use haloperidol or atypical antipsychotics prophylactically for delirium prevention 1
• Avoid benzodiazepines as they are an independent risk factor for delirium development 1

Treatment

• For delirium unrelated to alcohol/benzodiazepine withdrawal, use dexmedetomidine rather than benzodiazepine infusions for sedation 1
• Atypical antipsychotics may reduce delirium duration but avoid in patients with QT prolongation or torsades de pointes risk 1
• Do NOT use rivastigmine for delirium treatment 1

Sleep Optimization

• Promote sleep by optimizing the ICU environment: control light and noise, cluster patient care activities, decrease nighttime stimuli 1
• Use sleep-promoting protocols that include offering earplugs and eyeshades to all patients 1
• If sedation is required overnight in hemodynamically stable patients, dexmedetomidine may improve sleep architecture (increases stage 2 sleep, decreases stage 1 sleep) though it does not increase deep or REM sleep 1
• Do NOT use propofol specifically to improve sleep as it suppresses REM sleep and causes hemodynamic/respiratory side effects 1

Non-Pharmacological Interventions

• Integrate music therapy to reduce procedural and resting pain 2
• Use massage therapy to decrease pain intensity and anxiety 2
• Encourage family presence and engagement, which significantly decreases delirium odds (OR 0.73) 1
• Consider relaxation techniques and environmental optimization as opioid-sparing strategies 2

Protocol Implementation

Barriers to Address

• Only 60% of US ICUs have implemented PAD protocols, and adherence is often poor 1
• Common barriers include: inadequate knowledge, physician/nursing workload, poor team communication, patient instability, and lack of systematic training 1
• Solutions: education programs, interdisciplinary team approach, systematic training, and recognition of institutional barriers 1

Care Bundle Approach

• Implement ABCDEF bundles (Awakening trials, Breathing trials, Coordination, Delirium monitoring, Early mobility, Family engagement) together for synergistic benefits 1
• Bundled interventions show greater combined benefits than individual components for patient outcomes 1

Special Populations

Cardiovascular ICU Patients

• Sedative selection is critical due to hemodynamic effects in critically ill cardiac patients 1
• Fentanyl is preferred over morphine in renal failure due to lack of active metabolites 1

COVID-19 Patients

• Avoid deep sedation and benzodiazepines despite pandemic-related challenges (understaffing, drug shortages) 1
• Early deep sedation in COVID-19 patients was independently associated with worse clinical outcomes including prolonged mechanical ventilation and increased delirium 1

Common Pitfalls

• 40% of ICU patients still experience moderate-to-severe pain despite decades of emphasis on pain management 1
• Deep sedation remains overused (40-50% of assessed patients are deeply sedated) despite evidence of harm 5
• Procedural pain is specifically managed in less than 25% of cases 5
• Medication-induced coma is NOT humane; light sedation with patient responsiveness is superior for outcomes 1